As a provider, it can be daunting to introduce new tools into your practice. This is especially true if the tools in question have potential to compromise your practice, or your relationships with your clients. Practitioners must always strive to remain on the right side of ethical practice while using new technological advancements. In an effort to increase convenience and introduce new technology providers can easily misstep, especially when there are almost no real guidelines in existence for how to use online services, like video conferencing or messaging. Tools such as these are still very new to care, and are not always introduced with an ethical framework to support them in practice.
With regulatory bodies such as colleges, hospitals, and insurance companies moving relatively slowly to create such guidelines (ie. legal, privacy, ethical considerations), standards of care will need to be introduced by individual organizations. Since its inception, OnCall Health has prioritized security and privacy. The guidelines that we present in the following post are recommendations and considerations for providers looking to gain a deeper understanding of online counselling ethics. For more information about how your practice or college operates in terms of providing ethical care, please contact your supervisor, clinical director, or college directly. Let’s explore some of the ethical issues worth considering as a provider looking to incorporate virtual care into your practice.
In our time operating, many factors that have been brought to our attention that are important to anyone seeking to operate ethically while using online virtual care tools. These factors are as follows:
- Access is Global, Licensing is Not
- Privacy Matters
- One Size Does Not Fit All
- Reasonable Understanding
- Standard of Care
- Boundaries (and other factors)
Let’s go through all of these factors to better understand their impact on providing virtual care ethically.
Access is Global, Licensing is Not
Virtual care has huge potential to positively impact the lives of patients and providers worldwide. One positive of virtual care includes increased accessibility to medical care for patients irrespective of where they live. Anyone with a webcam, microphone and an internet connection can meet with their provider virtually if they would like to. This has dramatically increased the ability of those who live in rural areas, or who must travel to receive care, to participate in appointments, receive treatment, and reduce overall costs associated with their care. For providers, this is advantageous as well, as travelling to see clients can also be reduced through using virtual care. Reducing the number of appointment cancellations and no-shows through the alternative of virtual appointments can also earn providers income that would otherwise be lost.
Virtual care can also open providers up to potentially tricky situations if they are not careful. For instance, having care options where new and previously unknown clients can request an appointment may provide new business, but it also requires extra scrutiny. For example, providers must be aware of the province or state their clients live in. Providers are licensed and governed by organizations, which are responsible for ensuring the therapist in question has met their educational requirements and upholds standards of care for that region. Providers practicing therapy online have the potential to connect with clients outside of their licensing jurisdiction. This can be problematic for both parties due to insurance restrictions, jurisprudence, and the aforementioned college requirements.
It is necessary for providers to request and/or understand all pertinent information on the limitations of their license, and where they can legally practice to ensure the best outcomes for themselves and their clients.
Privacy is a foundational aspect of any patient-provider relationship. Integrating a new platform into one’s practice can potentially have a negative effect on the privacy of the patient-provider relationship (if information is lost, files don’t send, information is not protected, etc). Altering one’s practice to include a new piece of technology can affect the level of privacy clients and providers experience; but it doesn’t have to.
Firstly, it is important to align one’s practice with tools that reflect the nature of the work being performed. Using video conferencing tools that are not compliant with relevant privacy or health information laws exposes patients and providers to undue and unnecessary risk. Email is one example of a commonly used tool that is not secure in terms of transmitting personal health information. Many patients and providers use email to discuss private or confidential information that could be seen or obtained by unauthorized parties. Unless a service is explicitly compliant with privacy laws or patient health information laws, it should not be assumed that it is a private or compliant channel.
When selecting a virtual conferencing tool, ensure that your security needs align with those of the platform. Clients must also be aware of how their personal health information may or may not be accessed through the use of the platform. One of the best practices for working with clients through a virtual care platform is for providers to be able to assure clients that the telehealth platform has a low level of risk for unauthorized access to medical or personal information. Practitioners must take certain steps to ensure clarity in process, i.e. letting clients know that they will be asked to consent to online services, and then fill out an intake form. From there, the information will be stored by company X in X location. The limitations of virtual care should also be discussed to ensure clients are prepared to participate in online video counselling.
One Size Does not Fit All:
It is incumbent upon providers to ensure they are not advancing telehealth services on clients who desire, or would benefit from, in person care. Virtual care is best used as an integrated part of an existing practice, such as accessing distance clients, during periods of inclement weather, for check-ins while providers or clients are away. Mixed care can often improve client-provider relationships by increasing the number of potential interactions between clients and providers.
There are many situations where having in-person appointments alongside a virtual care solution that is integrated can be extremely beneficial. If clients are having a difficult time leaving their house, impacting attendance for scheduled appointments, it can be beneficial to offer a therapy that is not as dependent on one physical location. On the other hand, some individuals prefer the connection they experience by coming in to a brick-and-mortar office space, or the feeling of having a dependable routine. Therapists must strive to find a balance between providing in person services and virtual care to ensure clients are able to receive the most appropriate care. In addition, clients should be aware of all solutions offered by their provider. Malpractice charges can be warranted if helpful tools were offered by the provider or their clinic, but the client was not made aware of them, and as a result of not being made aware, harm or damages were incurred.
Another important issue is that of provider-client boundaries, to be discussed in more detail later on.
This section will examine the legal and ethical implications of using technology with regards to the healthcare industry. Reasonable understanding is a useful phrase to remember when considering how to remain ethical when incorporating tools into one’s practice. Being ‘reasonable’ under the law has a strict and objective definition. ‘Reasonable’ can be defined thusly:
“What is reasonable depends on the facts of each case, including the likelihood of a known or foreseeable harm, the gravity of that harm, and the burden or cost which would be incurred to prevent the injury. In addition, one may look to external indicators of reasonable conduct, such as custom, industry practice, and statutory or regulatory standards.”
-Ryan v. Victoria (City),  1 SCR 201) via Law Now
Other factors that may be considered in defining what is considered reasonable are whether or not a person exercised a standard of care that would be expected of an ordinary and prudent person in the same circumstances to avoid liability.
The purpose of providing this explanation is to ensure that providers who are seeking to incorporate virtual care into their practice are aware of the fact that having a reasonable understanding of the platform is an ethical requirement. Providers should consider the benefits of being trained in delivering virtual care services, or at the very least, take reasonable steps to ensure their competence with the technology being used and the potential consequences, or the impact of, technology on clients and patients. It is also important that any provider using or planning on using virtual care should be comfortable communicating electronically with their clients.
Of course, clients must have a reasonable understanding of what the platform can provide for them as well, with the same standards applying to judge reasonableness. Clients must have the opportunity understand what online counselling entails; to consent to online services, to ensure they understand the terms and conditions of the platform in question, and to gain an understanding of the choice to participate or not in said services.
Standard of Care:
Standard of care refers to a standard of practices accepted by professionals in the care community. “Standard practices” are determined by what an average practitioner having the same or similar education and training would do in the same or similar conditions. Actual standard of care practices are context-based, which can lead to some difficulty, especially when providing services to clients who are located in a different area than the provider.
A standard of care should be enforced as a necessary component of any type of care, including virtual care, when constructing ethical guidelines. Many considerations must be made to ensure clients are receiving the same, similar, or improved care to what they would be if they were attending in-person sessions. Conditions for standards of care must be identified, such as how content is experienced online, whether or not clients are ever referred from one type of care to another where appropriate, ensuring protocols meet or exceed standards or care for in-person treatment, ensuring there is a back up for any technical malfunctions, and potentially even establishing access to virtual care as a part of overall ethical considerations. Standards of care are also connected to the prior section One Size Does Not Fit All in that failing to meet standards of care can be considered negligence and grounds for legal proceedings and damages.
It will likely be a long time before a universal Standard of Care is introduced, or even standards which encapsulate the necessity of parity between virtual care services and in-person services. In the meantime, providers will still need guidance on how to provide virtual care services in a way that does not put themselves or their clients at risk.
Providers should contact their relevant regulatory or governing body for guidance on specific Standards of Care for their practice/region.
Boundaries & Other Factors Affecting Relationships:
Virtual care platforms have the capacity to disrupt and impact provider-patient relationships. Ethical considerations should be made with regards to minimizing harm, and optimizing treatment gains. Regardless of the medium of treatment, patients and providers must treat and behave as though they were in a brick-and-mortar office space during all therapeutic or care-related interactions. Choosing a platform that is built specifically for this type of interaction is one way to prevent casual or unprofessional encounters, versus utilizing a platform where clients are more used to having casual conversation.
Providing flexible service can be one way in which care professionals may be able to better accommodate their clients online. Flexibility should not be extended to the nature or organization of discussions, as care must not be confused with the frequent, casual interactions to be had with friends over social media, or other communications devices. There may be an underlying assumption that a physical boundary can protect providers from issues of transference and other boundary crossings or violations. This is simply not the case, and as a result, expectation management with clients is key to ensuring boundaries are firm from the outset. Clients should not, for example, expect instantaneous message responses, to have the ability to message their provider directly whenever they see fit, or to be in contact when their provider is not well through any virtual platform.
Self-care regulation is also an ethical consideration for providers who may be incentivized to practice when feeling ill, or on vacation. Boundaries from all sides are of the utmost importance, especially when operating with clients who are unfamiliar with technology, or who conduct themselves casually in online interactions. Setting clear boundaries about the way the platform is to be used, and how interactions will be maintained from the beginning of a relationship is the best way to ensure clarity and consistency throughout the relationship.